National Consumer Disputes Redressal
Mr. Satinder Singh vs National Insurance Co. Ltd. on 24 January, 2011
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 200 OF 2007 (From the order dated 24.10.06 in Appeal No.950/06 of the State Commission, Punjab) Mr.Satinder Singh Petitioner Versus National Insurance Co. Ltd. Respondent BEFORE : HONBLE MR. JUSTICE ASHOK BHAN, PRESIDENT HONBLE MRS.VINEETA RAI, MEMBER For Petitioner : Mr.Manoj Yadav, Advocate For Respondent : Mr.Tarun Arora, Advocate Pronounced on 24th January, 2011 ORDER
PER VINEETA RAI, MEMBER The present revision petition has been filed by one Satinder Singh (hereinafter referred to as the Petitioner) being aggrieved by the order of State Consumer Disputes Redressal Commission, Punjab (hereinafter referred to as the State Commission) in favour of National Insurance Co. Ltd. (hereinafter referred to as the Respondent).
The facts of the case according to the Petitioner are that he had purchased a medical claim policy from the Respondent Insurance Company for a period of one year from 29.03.2004 to 28.03.2005 and paid the required premium. At the time of taking the policy, he also made the necessary disclosures and nothing was concealed from the Insurance Company.
Suddenly, in December, 2004 the complainant felt exertion and he was taken to Deep Day Care Health Centre, Amritsar where he was treated upto 05.01.2005 and thereafter advised to go to the Escorts Hospital in Delhi for Angiography and other tests. The Petitioner went to Batra Hospital, New Delhi which is an approved hospital of the National Insurance Company where Angiography and other tests were performed and was diagnosed with Coronary Artery disease and angina on exertion class-III. It was specifically stated in the report by Batra Hospital that he was non-diabetic, non-smoker with no family history of CAD and the disease was a recent development. The Petitioner was advised a bye-pass surgery by the said hospital. When the Petitioner lodged a claim with the Respondent for his medical treatment at Batra Hospital, he was advised to go to Sir Ganga Ram Hospital for further treatment and surgery where a bye-pass surgery was conducted on him. The Petitioner thereafter submitted a claim for the medical expenditure which included Rs.1,52,047/- that was spent on his operation at Sir Ganga Ram and Rs.23,545/- at Batra Hospital. However, to his utter surprise the Respondent repudiated the claim on the ground that the present hospitalization was for management of an ailment which was related to a pre-existing disease and therefore was not admissible as per the Condition 4.1 of the said Insurance policy.
Aggrieved by this, Petitioner filed a complaint before the District Forum seeking Rs.1,74,582/- along with interest @ 12% per annum, compensation of Rs.50,000/- for deficiency in service, mental tension etc. as well as litigation cost.
The Respondent, however, denied these allegations and stated that it is very clear from the report of Sir Ganga Ram Hospital that the Petitioner was suffering from severe triple vessel coronary artery disease, hypertension, bilateral facial palsy as well as non-insulin dependant diabetes. These were obviously pre-existing diseases since they do not occur overnight and these facts were not disclosed by the Petitioner at the time of taking the policy and therefore, the claim was rightly repudiated.
The District Forum after hearing both parties and considering the evidence on record accepted the complaint on the ground that the claim was wrongly repudiated. The operative part of the order of the District Forum is reproduced:
The controversy which is required to adjudicated upon by this consumer forum narrows down to the fact as to whether the opposite party has proved its allegations that the ailment of the complainant was pre-existing as a result of which he is not entitled to claim the insurance amount on the basis of the mediclaim policy purchased by him in the sum of Rs.2 lacs. A careful scanning of the evidence of the opposite party revealed that except for relying on the clinical summary of Dharma Vira Heart Centre of Sir Ganga Ram Hospital, opposite party has not brought even a shred of an evidence to conclusively establish that complainant was taking treatment for his heart ailment from any hospital in India before taking the mediclaim policy.
It is well settled proposition of law that he who alleges the fact, must prove the same through cogent and convincing evidence. In the case in hand it has been alleged by the opposite party that the ailment of the complainant was pre-existing. It was naturally for the opposite party to have proved this allegation beyond doubt in order to justify the repudiation of his claim. But opposite party has heavily relied on case history of the complainant report at Sir Ganga Ram Hospital and produced in the Forum as exbt.R-2. It is recorded by the doctors of Sir Ganga Ram Hospital that Sard Satinder Singh, 51 years old pleasant gentleman, has been having angine on exertion off and on for last one month.
Currently, he is NYHA class III symptomatic. His Coronary angiography revealed severe triple vessel coronary artery disease with mild LV dysfunction.
His coronary risk factors are NIDDM and systemic hypertension. As has already been discussed, no other evidence has been brought on record by the opposite party. The doctor making the above said report has also not been examined by the opposite party nor his sworn affidavit has been tendered into evidence. It has by now become a well settled proposition of law that recording of the history of a patient in the above stated manner, does not become a substantive piece of evidence unless a very cogent and convincing evidence has been brought on record to establish that insured was suffering from a pre-existing for which he had been taking treatment or remained admitted to some hospitals. The records or doctor of such a hospital should be proved/examined.
Document exbt.R-3 is a repudiation letter and its close perusal shows that opposite party has very heavily relied on the clinical history of the patient recorded at Sir Ganga Ram Hospital at the time of his admission concluding that complainant was suffering from a pre-existing disease and as such, his claim is not payable in view of the exclusion clause 4.1 contained in the terms and conditions of the insurance policy. As has already been discussed, no other evidence at all has been brought on record by the opposite party to establish that ailment of the complainant was pre-existing to justify the repudiation of his claim.
The District Forum directed the Respondents to pay a sum of Rs.1,74,602/- to the complainant with interest @ 6% per annum from the date of repudiation till the date of payment as well as Rs.1,000/- as costs. Aggrieved by this ruling, Respondent filed an appeal before the State Commission which accepted the appeal on the grounds that the Respondent suppressed material information that he had pre-existing disease at the time when he took the policy. The State Commission recorded the following reason for reaching this conclusion:
Learned counsel for the appellant has brought to our notice the Discharge Summary regarding the insured complainant prepared at Sir Ganga Ram Hospital, New Delhi. Against the colum Diagnosis, it has been mentioned severe triple vessel coronary artery disease. It has also been mentioned Mild LV dysfunction. Even in the Clinical Summary it has been mentioned, His coronary angiography revealed severe triple vessel coronary artery disease with mild LV dysfunction. Severe triple vessel coronary artery disease does not occur overnight. It takes sufficiently long time before this disease occurs and, in the present case, it was not one artery but three arteries which were affected by the disease.
In common parlance, it is blockage of the coronary arteries going to the heart, which obstructs the flow of blood to the heart, which may result in breathlessness or even heart failure.
In the present case, this medial treatment was under taken by the complainant after about ten months of the taking of the mediclaim policy. As observed above, we are of the view this severe triple vessel coronary artery disease must be in existence(emphasis supplied) at the time when the complainant took the policy.
Hence, the present revision petition.
Learned counsel for both parties were present.
Counsel for Petitioner stated that the medical records from both hospitals clearly indicated that there was no history of any heart disease or any other serious symptoms and the record of Sir Ganga Ram Hospital on which the State Commission has relied, also specifically recorded in its clinical summary that the symptom of angina on exertion occurred only one month prior to Petitioner being examined at Sir Ganga Ram Hospital. On the other hand, Respondent was not able to produce any cogent evidence to legally justify its repudiation. In fact, the onus to prove that the Petitioner had suppressed any material information or facts regarding pre-existing disease was on the Respondent. The State Commission reached its conclusion purely on the basis of conjecture and erroneously ruled in favour of the Respondent. This order, therefore, needs to be set aside.
Counsel for Respondent reiterated that as per the records of Sir Ganga Ram Hospital, the Petitioner was suffering multiple serious diseases which included non-insulin dependant diabetes as well as coronary heart disease. In a case where three arteries are affected requiring bye-pass surgery, it is not possible that the symptoms will occur overnight and thus, it is not possible that the Petitioner was unaware of his medical condition till a month before his operation.
We have heard learned counsel for both parties and have carefully gone through the evidence on record. We note that the Petitioners medical summary from both, Sir Ganga Ram Hospital and Batra Hospital states that the complaints for which the patient was treated was a recent occurrence. Both hospitals emphasized that he has no history of any serious disease and that he had experienced angina pains and related symptoms only a few weeks before his admission to the hospital. This makes it clear that the symptoms became known to the Petitioner after he had taken the medical insurance policy. The Respondent has also not been able to produce any evidence to the contrary nor has it been able to show that the Petitioner had ever taken medical treatment for his heart condition prior to his admission in the hospital in Amritsar (which was after taking the medical insurance) and subsequently in the two hospitals in Delhi. The conclusion of the State Commission that the Petitioner must be having pre-existing is based on guess work and not on any concrete or specific evidence to support this statement. The order of the State Commission is, therefore, erroneous and cannot be sustained and set aside. We uphold the order of the District Forum. The Respondent is directed to pay the Petitioner Rs.1,74,602/- with interest @ 6% per annum from the date of repudiation till the date of payment along with costs of Rs.1,000/-. The revision petition is allowed.
..
(ASHOK BHAN J.) PRESIDENT ..
(VINEETA RAI) MEMBER /sks/